There is confusion about the value of treatment of sperm autoimmunity in the literature. This is partly related to the lack of understanding about the need to separate patients with sperm autoimmunity from those with low levels of sperm antibodies that do not contribute significantly to the infertility. The latter type of patient may achieve pregnancies by a variety of methods, including artificial insemination and standard in vitro fertilization, both of which techniques produce very poor results in patients with sperm autoimmunity. Some studies, however, do not differentiate these patient groups, and thus produce controversial results. Because of the poor prognosis for natural conception, artificial insemination, or standard in vitro fertilization in cases with sperm autoimmunity, donor insemination is also an option for these couples. If donor insemination is used, it is necessary to tell the couple to avoid coitus within 48 hours of insemination, as the antibodies in the man’s semen could affect the donor sperm.
Intracytoplasmic Sperm Injection (ICSI)
Intracytoplasmic sperm injection is now the primary method of treatment for sperm autoimmunity. Provided the sperm are alive, outcomes tend to be good. Sperm antibodies do not appear to have an adverse effect on the outcome of intracytoplasmic sperm injection. In fact, reports indicate that intracytoplasmic sperm injection generally produces good results when compared to historical controls that utilized standard in vitro fertilization without glucocorticoid treatment of the men. There also have been comparative studies that clearly demonstrate higher fertilization rates with intracytoplasmic sperm injection than standard in vitro fertilization using a random selection of oocytes from each patient for intracytoplasmic sperm injection or in vitro fertilization.
Before the introduction of intracytoplasmic sperm injection, standard in vitro fertilization produced poor results with patients with severe sperm autoimmunity. If sperm antibody levels were reduced with prednisolone treatment the results were reasonable. A controlled trial by Lahteenmaki et al. (Ill) with prednisolone showed no improvement with fertilization rate over that with placebo, but the dosing regimen was very modest at only 20 mg daily for 10 days. As can be expected, there was no effect on antibody levels. It should be noted, however, that this group later found that a low dose of prednisolone was, in fact, able to reduce antibody levels in some patients if the treatment course were prolonged to a total of 21 days.
Standard methods are used for preparation and injection of sperm intracytoplasmic sperm injection. Some protocols require the man to ejaculate into approximately 50 ml of culture medium in order to reduce the amount of antibodies bound to the sperm. If no motile sperm are present in the fresh or cryopreserved semen, pentoxifylline or hypoosmotic swelling may be used to select live sperm; testicular biopsy may also be used to obtain elongated spermarids for intracytoplasmic sperm injection.
Fertilization rates are low if immotile sperm are injected. Otherwise, the results appear to be the same as for other types of male infertility that can be treated successfully with intracytoplasmic sperm injection. Not to be discounted are the influences of female factors, particularly age. In women under 35 years of age, about 35% to 40% will be able to conceive with embryo transfers obtained from each multiple oocyte collection.
The complications of intracytoplasmic sperm injection in women include ovarian hyperstimulation syndrome, bleeding, infection from the oocyte collection procedure, and multiple pregnancies when more than one embryo is transferred. These complications are not specific to sperm autoimmunity, and occur with intracytoplasmic sperm injection performed for other reasons.